Healthcare Provider Details

I. General information

NPI: 1386089050
Provider Name (Legal Business Name): SAMANTHA GREGORY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10515 W MARKHAM ST STE E1
LITTLE ROCK AR
72205-2292
US

IV. Provider business mailing address

9300 TWIN MOUNTAIN LN
ROLAND AR
72135-9024
US

V. Phone/Fax

Practice location:
  • Phone: 501-343-4225
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number920090677
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: